aetna breast reduction requirements

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Plast Reconstr Surg. 2002;33:208-217. Gynecomastia in patients with prostate cancer: A systematic review. For these reasons, there is insufficient evidence to support the use of reduction mammoplasty, without regard to the size of the breasts or amount of breast tissue to be removed, as a method of relieving chronic back, neck, or shoulder pain. 2009;7(2):114-119. Reduction mammoplasty is among the most commonly performed cosmetic procedures in the United States. Aetna considers associated nipple and areolar reconstruction and tattooing of the nipple area medically necessary. The author concluded that the current level of evidence on this subject was very low and future studies, examining the impact of the surgical intervention for gynecomastia on psychological domains, are greatly needed. color:#eee; Role of tamoxifen in idiopathic gynecomastia: A 10-year prospective cohort study. Sixteen (23%) patients had complications and higher resection weight, increased BMI, and older age were found to have statistically significant complication rates with p-values of p<0.001, p=0.034, and p=0.004, respectively.The investigators also found that the incidence of complications was highest among current smokers and lowest among those who had never smoked with a 37% difference in the occurrence of complication (p<0.01). list-style-image: url('https://www.aetna.com/cpb/medical/data/assets/images/purplearrow.jpg') !important; 1999;103(1):76-82; discussion 83-85. Burns JL, Blackwell SJ. This Clinical Policy Bulletin may be updated and therefore is subject to change. Abnormal histopathology correlated with higher age (p = 0.0053), heavier specimen (p = 0.0491), and with no previous breast surgery (p < 0.001). Aetna has their own sliding scale which requires more from smaller patients relative to the Schnur scale, but maxes out at 1000 gms per breast. 2006;9(2):109-114. .headerBar { Thus, more than 1/3of operative subjects selected for inclusion in the study did not complete it; most of the operative subjects who did not complete the study were lost to follow-up. A study by Glatt et al (1999) was a retrospective analysis of responses to questionnaires sent to patients who underwent reduction mammoplasty regarding physical symptoms and body image. Surgical implications of obesity. Wound drainage after plastic and reconstructive surgery of the breast. Administration of Benefits and Transition Responsibilities J Plast Reconstr Aesthet Surg. Last Review01/04/2023. The operative group in the BRAVO study was drawn from a number of surgical practices that volunteered to participate in the study; no details are provided about how each center selected candidates for reduction mammoplasty, or how they chose patients who underwent mammoplasty for inclusion in the study. Reduction mammoplasty has been performed to relieve back and shoulder pain on the theory that reducing breast weight will relieve this pain. Reduction mammoplasty also known as breast reduction surgery, is a surgical procedure in women to reduce the weight, mass, and size of the breast. 1993;91(7):1270-1276. The authors of the BRAVO study reached several conclusions about reduction mammoplasty, most notably that breast size or the amount of breast tissue removed does not have any relationship to the outcome of breast reduction surgery (Kerrigan et al, 2002; Collins et al, 2002). Gynecomastia, its etiologies and its surgical management: A difference between the bilateral and unilateral cases? Alternatively, you may qualify if your breast size causes significant symptoms, such as: Long-term neck, shoulder or neck pain. Please check your insurance policy to see whether breast reduction is a covered procedure. Reduction mammoplasty has also been used for relief of pain in the back, neck and shoulders. } Ann Plastic Surg. Sood R, Mount DL, Coleman JJ 3rd, et al. Aetna and the City shall each abide by all applicable laws, regulations and government requirements regarding the confidentiality and the safeguarding of individually identifiable health and other personal information, including the privacy and security requirements of HIPAA. list-style-type: upper-roman; Pain/discomfort/ulceration from bra straps cutting into shoulders; Skin breakdown (severe soft tissue infection, tissue necrosis, ulceration hemorrhage) from overlying breast tissue; There is a reasonable likelihood that the member's symptoms are primarily due to macromastia; Reduction mammoplasty (also spelled as 'mammaplasty') is likely to result in improvement of the chronic pain; Pain symptoms persist as documented by the physician despite at least a 3-month trial of therapeutic measures such as: Analgesic/non-steroidal anti-inflammatory drugs (NSAIDs) interventions and/or muscle relaxants, Dermatologic therapy of ulcers, necrosis and refractory infection, Physical therapy/exercises/posturing maneuvers, Supportive devices (e.g., proper bra support, wide bra straps), Chiropractic care or osteopathic manipulative treatment. .strikeThrough { } The surgeon estimates that at least the following amounts (in grams) of breast tissue, not fatty tissue, will be removed from each breast, based on the member's body surface area (BSA) calculated using theMosteller formula. Grade IV: Marked breast enlargement with skin redundancy and feminization of the breast. A total of 90 patients underwent breast re-reduction surgery. 2015;75(4):383-387. Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture. In a within-patient, randomized, patient- and assessor-blinded, controlled study, Anzarut et al (2007) evaluated the use of completely autologous platelet gel in 111 patients undergoing bilateral reduction mammoplasty to reduce post-operative wound drainage. Policy Statement 6d: Aesthetic surgery procedures. Iwuagwu OC, Stanley PW, Platt AJ, Drew PJ. The authors concluded that the vacuum-assisted breast biopsy system could be used as a feasible and minimally invasive approach for the treatment of gynecomastia. Reduction mammoplasty for asymptomatic members is considered cosmetic. Two review authors undertook independent data extraction of study characteristics, methodological quality and outcomes (e.g., infection, other wound complications, pain, and length of hospital stay [LOS]). These investigators retrospectively examined 83 patients with gynecomastia between January 2015 and December 2019. Bland KI, Copeland EM, eds. Also, there was no correlation between PR expression and 2D: 4D. 1969;44(235):291-303. Surgical treatment of gynecomastia by vacuum-assisted biopsy device. A total of 182 thirty-day postoperative surgical complications were documented, but stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). No author listed. Within this study population, 54.4% of patients were obese (BMI > 30 kg/m2), of which 1308 (28.8%) were Class I (BMI = 30-34.9 kg/m2), 686 (15.1%) were Class II (BMI = 35-39.9 kg/m2), and 439 (9.7%) were Class III (BMI > 40 kg/m2). Breast. Plast Reconstr Surg. Ann Plast Surg. J Plast Reconstr Aesthet Surg. Gynecomastia may be drug-induced. J Pediatr Surg. Surgical management of gynecomastia--a 10-year analysis. In a review on Surgical treatment of primary gynecomastia in children and adolescents, Fischer et al (2014b) concluded that surgical correction of gynecomastia remains a purely elective intervention. Chemical peels (chemical exfoliation): Considered medically necessary when criteria in CPB 0251 - Dermabrasion, Chemical Peels, and Acne Breast re-reduction surgery was most commonly performed using a random pattern blood supply, rather than recreating the primary pedicle [n = 77 (86 %)]. Ann Plast Surg. The majority (87.7 %) of cases presented with accompanying mastalgia. Breast Reduction Surgery | Johns Hopkins Medicine Results illustrated that 3050 patients were <60 years of age (39.7 11.8 years) and 487 were 60 years of age (65.1 4.7 years). #backTop:hover { } Reduction mammaplasty. There were no statistically significant differences between the 2 vacuum-assisted breast biopsy systems according to the mean age, the mean operation time, sites, or grade. Surg Laparosc Endosc Percutan Tech. display: none; The mean volume of tissue resected was 250 g (range of 22 to 758 g) from the right breast and 244 g (range of 15 to 705 g) from the left breast. Brown MH, Weinberg M, Chong N, et al. Obesity and complications in breast reduction surgery: Are restrictions justified? PDF A look at new changes coming to E&M and breast coding in 2021 They investigated effects of age on 30-day surgical outcomes for reduction mammoplasty with a goal of improving patient care, counseling, and risk stratification on 3537 patients. Srinivasaiah N, Iwuchukwu OC, Stanley PR, et al. They also analyzed if timing of reduction mammoplasty in relation to oncological treatment influenced the incidence of abnormal findings, and compared if patients with abnormal contralateral histopathology differed from the study population in terms of demographics. For individuals who received radiation treatment to the chest . 1997;100(4):875-883. ASPS clinical practice guideline summary on reduction mammaplasty. Sugrue and associates (2015) evaluated the current practice patterns of drains usage by plastic and reconstructive and breast surgeons in United kingdom (UK) and Ireland performing bilateral breast reduction (BBR). border-radius: 4px; Variations in pattern of pubertal changes in girls. 1995;95(1):77-83. The primary outcome was the difference in wound drainage over 24 hours. Little is known about the effect of surgical treatment on the psychological aspects of the disease. } Mistry and associates (2017) examined outcomes following breast re-reduction surgery using a random pattern blood supply to the nipple and vertical scar reduction. See Appendix for Table 1. Patients in vacuum-assisted breast biopsy group had a better cosmetic outcome than those in open surgery group. J Laparoendosc Adv Surg Tech A. Pediatr Surg Int. The investigators reported that subjects who were of normal weight were as likely to report benefit from reduction mammoplasty as subjects who were over-weight. Nguyen JT, Wheatley MJ, Schnur PL, et al. The study consisted of 329 breast cancer patients, who underwent symmetrizing reduction mammoplasty between 1/2007 and 12/2011. Reduction mammaplasty: A review of managed care medical policy coverage criteria. He Q, Zheng L, Zhuang D, et al. A total of 3 RCTs were identified and included in the review out of 190 studies that were initially screened; all evaluated wound drainage after breast reduction surgery. Plastic Reconstruct Surg. The condition not only must be unresponsive to dermatological treatments (e.g., antibiotics or antifungal therapy) and conservative measures (e.g., good skin hygiene, adequate nutrition) for a period of 6 months or longer, but also must satisfy criteria stated insection I above. Quality of life after breast reduction. 2014b;48(5):334-339. Studies have suggested that 2.4% to 14% of breast reduction cases resulted in major complications and 2.4% . This trial included all male patients who presented to the authors breast clinic who were diagnosed with primary gynecomastia, and were treated with a trial of tamoxifen 10 mg daily therapy, over a 10-year period from October 2004 to October 2015. A total of 244 out of 1,628 patients with the average age of 23.13 years. In these cases, breast reduction for men may take 2 to 3 hours. Most UnitedHealthcare plans have a specific exclusion for breast reduction surgery except as required by the . However, these medications should be reserved for those with no decrease in breast size after 2 years. Liposuction was also used adjunctively in all cases (average of 455 cc; range, 50 to 1,750 cc). Although operative subjects were examined before and after surgery, there was no attempt to employ any blinded or objective measures of disability and function to verify these self-reports. A systematic review of patient reported outcome measures for women with macromastia who have undergone breast reduction surgery. The authors concluded that treatment of gynecomastia by the Mammotome device was distinctive, practicable in manipulation, safe, and could achieve excellent cosmetic results. Fourth, insurers have provided coverage for reduction mammoplasty in women with excessively large breasts; thus, the debate is about the effectiveness of removal of smaller amounts of breast tissue from women whose breast size most persons would consider within the normal range. Kasielska-Trojan A, Danilewicz M, Antoszewski B. Liposuction assisted gynecomastia surgery with minimal periareolar incision: A systematic review. Clinical outcomes in reduction mammaplasty: A systemic review and meta-analysis of published studies. A retrospective study of changes in physical symptoms and body image after reduction mammaplasty. Devalia HL, Layer GT. Plastic surgery for teenagers briefing paper. A cohort study of breast cancer risk in breast reduction patients. Drains were used significantly less by surgeons performing greater than or equal to 20 BBRs (p = 0.02). In the case of reduction mammoplasty for relief of back, neck and shoulder pain, Aetna has considered this procedure medically necessary in women with excessively large breasts because it seems logical, even in the absence of firm clinical trial evidence, that this excessive weight would contribute to back and shoulder pain, and that removal of this excessive breast tissue would provide substantial pain relief, reductions in disability, and improvements in function. (This refers to actual breast tissue only; any fatty tissue removed doesn't count.) Orthopedic or spine surgeon evaluation of spinal pain; Radiotherapy (for the prevention or management of gynecomastia recurrence); Vacuum-assisted breast biopsy system for treament of gynecomastia. } Of the responding surgeons, 71.6 % (151/211) routinely inserted post-operative drains, for a mean of 1.32 days. Level of Evidence = IV. A total of 15 articles met the inclusion criteria for review. Post-operative complications included 1 case of hematoma, but no nipple necrosis, local skin necrosis, or skin buttonhole occurred. J Plast Reconstr Aesthet Surg. Qu and colleagues (2020) examined the effectiveness of vacuum-assisted breast biopsy systems for the treatment of gynecomastia. 2012;69(5):510-515. Kinell I, Baeusang-Linder M, Ohlsen L. The effect on the preoperative symptoms and the late results of Skoog's reduction mammoplasty: A follow-up study on 149 patients. Sixty to 70% of males develop a transient subareolar breast tissue during their adolescence (Tanner Stages II and III). Gland Surg. Computed tomography scan of adrenal glands to identify adrenal lesions. Complications following radiotherapy were minor and self-limiting in all cases, restricted to minor skin reactions, and associated with larger radiotherapy doses delivered in fewer fractions. 2007;356(5):479-485. Impact of surgical treatment for gynecomastia appeared to be beneficial for several psychological domains. Grooving where the bra straps sit on the shoulder. This conclusion is based primarily upon the Breast Reduction Assessment of Value and Outcomes (BRAVO) study, which is described in several articles (Kerrigan et al, 2001; Kerrigan et al, 2002; Collins et al, 2002). Copyright Aetna Inc. All rights reserved. 2015;49(6):311-318. Autorino R, Perdona S, D'Armiento M, et al. The investigators found that comorbid conditions increased across obesity classifications (p < 0.001), with significant differences noted in all cohort comparisons except when comparing class I to class II (p = 0.12). All studies on the subject were evaluated for inclusion and 6 studies were included in the review. Arch Dis Child. Based largely upon these results, Nguyen et al (2004) reached the conclusion that a trial of conservative management is not an appropriate criterion for insurance coverage, even though responses to the BRAVO questionnaire indicated that operative candidates and hypertrophy controls received at least some pain relief from all of the conservative interventions, and for some conservative interventions, virtually all subjects reported at least some pain relief. Flancbaum L, Choban PS. It is not intuitively obvious, however, that breast weight would substantially contribute to back, neck and shoulder pain in women with normal or small breasts. However, it is unclear if there is any evidence to support this practice. Arlington Heights, IL: ASPS; March 9, 2002. The operation was successfully performed in all 20 patients with a mean operating time of 51 mins and a hospital stay of 4 days. Can objective predictors for operative success be identified? The characteristics of patients as well as the curative effects between the 2 groups were analyzed. Does Blue Cross Blue Shield Cover Breast Reduction Surgery? - HelpAdvisor Plast Reconstr Surg. In a systematic review, Prasetyono and colleagues (2021) examined the quality of studies and re-visited liposuction-assisted gynecomastia surgery performed via minimal incision. .strikeThrough { Tobacco use and body mass index as predictors of outcomes in patients undergoing breast reduction mammoplasty. Am Surg. The authorsleave the reader with the conclusionthat decisions about the medical necessity of breast reduction surgery in symptomatic women should be left entirely to the surgeon's discretion. Abnormalities in Adolescent Breast Development. Handschin AE, Bietry D, Hsler R, et al. Effects of reduction mammaplasty on pulmonary function and symptoms of macromastia. Work-up of gynecomastia may include the following (GP Notebook, 2003): Treatment should be directed at correcting any underlying reversible causes. Plast Reconstr Surg. color: red!important; Ann Plast Surg. Major complications (1.6 %) included unilateral hematoma and localized infection. Aetna considers molecular susceptibility testing for breast and/or epithelial ovarian cancer ("BRCA testing") medically necessary once per lifetime in any of the following categories of high-risk adults with breast or epithelial ovarian cancer (adapted from guidelines from the U.S. Preventive Services Task Force (for Completely autologous platelet gel in breast reduction surgery: A blinded, randomized, controlled trial. For pain interventions, evidence of effectiveness is necessary from well controlled, randomized prospective clinical trials assessing effects on pain, disability, and function. Risk factors for complications following breast reduction: Results from a randomized control trial. Kalliainen LK; ASPS Health Policy Committee. Three review authors undertook independent screening of the search results. 2013;71(5):471-475. Gynecomastia: Evolving paradigm of management and comparison of techniques. Subgroup analysis further stratified the younger cohort into those <50 years and 50-60 years of age. Nelson JA, Fischer JP, Wink JD, Kovach SJ 3rd. In a majority of boys with pubertal gynecomastia, the condition resolves within 18 months. Krieger LM, Lesavoy MA. Annu Rev Med. 1998;26(1):61-65. He and associates (2011) examined the safety and feasibility of vacuum-assisted biopsy device in the treatment of gynecomastia. Am J Infect Control. Only 8 (9.9 %) patients did not have a complete resolution following tamoxifen therapy, of which 2 underwent subsequent surgical resection of their symptomatic gynecomastia. Chadbourne EB, Zhang S, Gordon MJ, et al. Anzarut A, Guenther CR, Edwards DC, Tsuyuki RT. Furthermore, there is insufficient evidence that surgical removal is more effective than conservative management for pain due to gynecomastia. Qu S, Zhang W, Li S, et al. Fischer JP, Cleveland EC, Shang EK, et al. Clinical Policy: Reduction Mammoplasty and Gynecomastia Surgery - WellCare Harmonic scalpel versus electrocautery in breast reduction surgery: A randomized controlled trial. What are Aetna breast reduction requirements? - RealSelf.com 2017;139(6):1313-1322. Reduction mammoplasty: Criteria for insurance coverage. Well-designed, prospective, controlled clinical studies have not been performed to assess the effectiveness of surgical removal of modest amounts of breast tissue in reducing neck, shoulder, and back pain and related disability in women. American Society of Plastic Surgeons (ASPS). Karamanos et al (2015) noted that although breast reduction mammoplasty accounts for more than 60,000 procedures annually, the literature remains sparse on outcomes. An 18-question survey was created evaluating various aspects of BBR practice; UK and Irish plastic and reconstructive and breast surgeons were invited to participate by an e-mail containing a link to a web-based survey. Data was then analyzed for surgical complications, wound complications, and medical complications within 30 days of surgery on 4545 patients. For example, at a body surface area of 1.5m, Aetna requires a minimum weight of 385 grams removed from each breast, whereas the Schnur scale would only require 260g. OL OL OL OL OL LI { Khan SM, Smeulders MJ, Van der Horst CM. Aesthetic Plast Surg. Breast reduction surgery - Mayo Clinic Patients were randomized to receive the gel applied to the left or right breast after hemostasis was achieved; the other breast received no treatment. Schnur PL, Schnur DP, Petty PM, et al. Schnur PL, Hoehn JG, Ilstrup DM, et al. In Type I (idiopathic) gynecomastia, the adolescent presents with a tender, firm mass beneath the areola. 2017;35:157-161. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna . 2006;118(4):840-848. Townsend: Sabiston Textbook of Surgery. Washington, DC: ACOG; 2011:121-122. Other referencesto smaller studies published prior to the BRAVO study have been cited,examining symptoms before and after reduction mammoplasty; each of these studies suffer from limitations similar to those identified with the BRAVO study. 1999;103(6):1674-1681. This Clinical Policy Bulletin addresses breast reduction surgery and gynecomastia surgery. } Current practice patterns of drain usage amongst UK and Irish surgeons performing bilateral breast reductions: Evidence down the drain. However, the measuring method of satisfaction rate varied, resulting in difficulties to interpret the results. If breast growth has been completed, breast reduction surgery is an option. Marshall and Tanner (1969)shows that the final stage of breast maturityoccurs about age 15 on average, but there is wide variation. Burdette TE, Kerrigan CL, Homa KA. Study appraisal was carried out using MINORS to evaluate the methodological quality of the paper. 2008;53(3):255-261. The mean age was 42.8 years (SD 19.5 years). The traditional method of breast reduction requires an open incision around the areola extending downward to the crease beneath the breast. A retrospective review was conducted of patients who underwent bilateral breast re-reduction surgery performed by a single surgeon over a 12-year period. When seeking preauthorization for a breast reduction, your goal is generally twofold. Examining any complication, a significant increase was noted with increasing obesity class (p < 0.001). Breast asymmetries: A brief review and our experience. 2015;75(4):370-375. Mannu GS, Sudul M, Bettencourt-Silva JH, et al. Moreover, these researchers stated that further studies are needed within the common gynecomastia population managed by plastic surgeons to examine the clinical and economical utility of this intervention before a recommendation for its ubiquitous adoption in plastic surgery can be made to continue improving outcomes for high-risk gynecomastia patients. Drainage in breast reduction surgery: A prospective randomised intra-patient trail. Breast reduction, also known as reduction mammaplasty, is a procedure to remove excess breast fat, glandular tissue and skin to achieve a breast size more in proportion with your body and to alleviate the discomfort associated with excessively large breasts (macromastia). Aesthetic Plast Surg. A total of 211 responding surgeons were analyzed, including 80.1 % (171/211) plastic surgeons and 18.9 % (40/211) breast surgeons. The average age of the studied individuals was 25.7 years (SD = 7.8); ER and PR expression was detected in breasts, and digit ratios were calculated in patients with idiopathic gynecomastia. The requirement for coverage is that the amount of breast tissue to be removed has to be enough to improve your symptoms or function. color: red Reduction mammaplasty: The need for prospective randomized studies. OL LI { 2006;30(3):309-319. 1993;17(3):211-223. } 2014a;34(1):66-73. Ann Plast Surg. Of these 33 operative sides, 2 complications occurred, but satisfactory chest contour was attained in all subjects. Kerrigan CL, Collins ED, Kneeland TS, et al. list-style-type: lower-roman; The investigators found little difference between obese and non-obese women concerning patient's reports of resolution of symptoms and improvement in body image. Prepubertal gynecomastia linked to lavender and tea tree oils. height:2px; }. The average interval between primary and secondary surgery was 14 years (range of 0 to 42 years). Breast Reduction Surgery and Gynecomastia Surgery - Medical - Aetna Anesthesia may be injected along with saline solution until the tissue is firm, and a suction cannula is used to extract fat from the breast. (25 y/o female with a 38J bra size) according to aetna, I should more than qualify for a reduction as I have back, neck, shoulder pain, chest pain and pressure, arm numbness while laying on sides, etc. Collis N, McGuiness CM, Batchelor AG. of the following criteria must be met: Plast Reconstr Surg. Plast Reconstr Surg. Aetna considers breast reduction surgery medically necessary for non-cosmetic indications for women aged 18 or older or for whom growth is complete (i.e., breastsize stable over one year) when any of the following criteria (A, B, or C) is met: Member has persistent symptoms in at leasttwoof the anatomical body areas below, directly attributed to macromastia and affecting daily activities for at least1 year: Member has severe breast hypertrophy, documented by high-quality color frontal-view and side-view photographs;and, Women50 years of age or older are required to have a mammogram that was negative for cancer performed within the twoyears prior to the date of the planned reduction mammoplasty;and.

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